Prototypical

I found myself blathering at Medgadget the other day about the inefficiencies of chest pain admissions. It made me nostalgic for my first patient I saw as a newly-minted physician, one Saturday morning back in July.

After days of orientation, and then a half-hour shadowing a senior in the Emergency Room, learning about the translator phone, computerized order-entry, and the nurse's names, I was eager to begin.

There was one chart in the to-be-seen rack. I picked it up. The triage note declared CHEST PAIN as the chief complaint.

I put the chart back down. "Probably not a good teaching case," I thought, recalling my medical school ER rotations. "And the attending will want to make the decision to rule him out for MI, herself."

I was ready to wait for another chart when it struck me: I'm not a student anymore. And today was a good day to get re-acquainted with a symptom I'll be encountering daily, for the rest of my career.

And so, I saw my first patient. He was in his early 50's, was mildly hypertensive on no meds, quit smoking, with no other risk factors. He reported a vague pressure pain around his sternum for the past few days, on and off, unrelated to exertion or meals. Pretty normal EKG, with no older ones on file.

I poked, I prodded, I tried to get his story and exam to lean one way or another. But his diagnosis remained ambivalent.

So, with a deep breath to acknowledge this momentous occasion, I wrote my first order as a physician:

Aspirin 325 mg PO x1.

The rest of the cardiac workup followed. It seemed a little dramatic to me, ordering all this bloodwork and monitoring for what would likely be reflux or costochondritis.

I was knee-deep in other patients, an hour or so later, when the attending pulled me aside.

"That first patient you saw, the rule-out MI?"

"Yeah?"

"He's ruling in."

"Really?"

She smiled. "Good pickup. I guess this bodes well for your career."

As I recall, the patient got cathed and did okay. And I haven't had much hesitation to rule out MI in the many, many ambiguous chest pain cases I've seen since.